ED Coding and Reimbursement Alert

Counting the right items, knowing insurer-allowed diagnoses, and documenting affected muscles will get your trigger point injection (TPI) claims paid while protecting you from paybacks.

Check out these coding do's and don'ts to optimize your TPI coding:

Coders should report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscles) when the physician injects one or two muscles, confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver.

When the physician injects three or more muscles, opt for 20553 (... single or multiple trigger point[s], 3 or more muscle[s]).

Remember, "coding is based on the number of muscles injected, not the number of trigger points in those muscles or the number of injections into those muscles," Hammer relays.

Patients suffering from muscle pain receive TPIs for relief; however, the types of pain that justify TPIs are entirely up to the payer.

Diagnoses that prove medical necessity for TPIs can vary. Some insurers cover only 729.1 (Myalgia and myositis, unspecified), while others have expanded the list of ICD-9 codes that support medical necessity for TPIs.

When your ED physician performs TPIs, "the most common diagnosis reported is 729.1," according to Judith Blaszczyk RN, CPC, ACS-PM, president of Veritas Consulting in Greencastle, Pa.

Best bet: Check with your payer for its specific list of acceptable ICD-9s on TPIs.

In addition to 729.1, 728.85 (Spasm of muscle) and 729.4 (Fasciitis, unspecified) are also common diagnoses for TPI, Hammer explains.

Here is a sampling of other acceptable ICD-9s for TPIs from the local coverage determination [LCD] for First Coast Service Options, a Florida Medicare carrier:

• 726.30-726.39 -- Enthesopathy of elbow region

• 726.70-726.79 -- Enthesopathy of ankle and tarsus

• 727.00-727.09 -- Synovitis and tenosynovitis.

When reporting TPI encounters, experts recommend including a list of the muscles the physician injects. "Since the coding is based on number of muscles, the provider should absolutely document the specific muscles injected," Hammer explains.

"Otherwise, the most that you could code is 20552, as the documentation could not support that three or more separate muscles were injected," she says.

Dry needling alert: If the physician performs "dry needling" rather than injecting a drug, most payers will not cover the injection. Providers should also include proof of the drug(s) the physician injected to ensure payment on TPIs.

Before submitting a TPI claim, you should check the specific substances your payer will accept on TPIs. Use the following J codes for drugs the physician might inject during TPI:

• J1020 -- Injection, methylprednisolone acetate, 20 mg

• J1030 -- Injection, methylprednisolone acetate, 40 mg

• J1040 -- Injection, methylprednisolone acetate, 80 mg.